There are a several therapies available for the treatment of primary insomnia, most notably cognitive-behavioral therapy (CBT) and pharmacologic treatment. The benzodiazepines are a group of chemically related compounds represented by medications such as triazolam, temazepam, and lorazepam. Non-benzodiazepines, such as zaleplon, zolpidem extended-release (ER), eszopiclone and zopiclone, act via a mechanism similar to the benzodiazepines but have a different chemical structure. Also available is the melatonin receptor agonist, ramelteon, as well as several antihistamines such as diphenhydramine, doxylamine, hydroxyzine.
Medications, such as the antidepressants trazodone, mirtazapine, doxepin, and amitriptyline as well as the antipsychotics, quetiapine, olanzapine, and risperidone, have been used off-label for the treatment of insomnia. Patients often turn to alcohol, over-the-counter agents, and melatonin for relief of their sleep problems (Slide 1).
Given these treatment options, there are several questions faced in clinical practice concerning when to treat patients for insomnia, what treatments should be used, and how long treatment should continue. CBT is typically continued for a fixed length of time. Generally, the greater the functional impairment a person experiences, the more there is to be gained from treatment. The decision about whether to treat and which treatments should be used, should consider the risks and expected benefits of all treatment options. CBT for insomnia has relatively minimal risks, with the only downsides being cost, access, and convenience. CBT should always be a therapeutic option.